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A TV journalist who has reported extensively on varied matters, from politics, religion, breaking news events to natural disasters. This is an attempt to create a space for larger and deeper issues that don't make the headlines. At least not enough

Family Planning

mMitra, started in Mumbai slums with the support of the civic body, is a free mobile voice call service that gives information on preventive care and simple interventions to reduce maternal and infant deaths. It is given in the language of the user’s choice and sent weekly or twice a week. Launched in 2014, it reaches over 5 lakh women in slums in Mumbai city, up to its far suburbs.

Domestic violence accounts for five in 10 of reported crimes against women in India. Many cases go undocumented, nearly 7 out of 10 women have suffered some form of domestic violence. Domestic violence is linked to posttraumatic stress disorder, gastrointestinal infections, suicide, chronic pain, and increased risk of unintended pregnancy, which, in turn, compromises maternal, infant and child health. The Little Sister’s Project, an initiative that works among victims of domestic violence in Mumbai, has 160 local women to identify and report incidents of gender violence using Android smartphones and an app called EyeWatch.

This documentary was done for the NDTV-Gates Foundation campaign, Every Life Counts. To watch click here

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From April this year, injectable contraceptives will be available in district hospitals across India.

At the recently held International Conference on Family Planning in Bali, top health ministry officials from India said that they were determined to meet their stated target of providing 48 million women with access to contraceptives by the year 2020.

In 2012, at the London Summit on Family Planning, India had pledged to commit almost $2 billion dollars until 2020. As a result, today more women and girls have access to family planning. In 2013 alone, three million additional women and girls in India were equipped with the tools and the information needed to choose a modern contraception method.

To fulfil this goal of 48 million, the government will increase the basket of contraceptive choices offered to women, and promote spacing between births. Apart from injectables, this will include Centchroman, a non-steroidal agent, and POPs or progesterone only pills.

Centchroman, marketed as Saheli, is a once-a-week oral contraceptive that acts on the hormones produced in the body, especially progesterone. POPs thicken the mucus in the cervix, stopping the sperm from reaching the egg.

“We are determined that no woman should be left behind and no partner be left behind,” said C.K Mishra, Mission Director, National Health Mission.

Phase 1 results from the fourth National Family Health Survey or NFHS-4 for 2015-16 that covered 13 States and two Union Territories are quite promising with total fertility rates or the average number of children per woman dropping considerably, ranging from 1.2 in Sikkim to 3.4 in Bihar.

All states in this phase, except Bihar, Madhya Pradesh and Meghalaya have either achieved or maintained replacement level of fertility and this is a major achievement in the past decade.

However, what remains problematic is the female sterilisation rate, which at 34% is very high. Health officials hope to bring down the numbers by offering more contraceptive choices and improving service delivery.

“All along there has been greater emphasis on terminal methods of family planning and we have not given spacing the attention needed,” said Mishra. “The goal ahead is to focus on adequate spacing”.

Also of concern is the total unmet need for contraception in India, which at 21.3% is the highest in the world. Bringing down the unmet need was a key Millennium Development Goals target that India was unable to meet.

A high unmet need for contraception translates into a high number of unintended pregnancies and has tremendous health implications. India accounts for 19% of the world’s maternal deaths and meeting the need for contraception is critical to saving lives.

“Today more girls and women have access to contraception but we are still 10 million behind in terms of what the figure should be,” said Chris Elias, president of the Global Development Program, Bill & Melinda Gates Foundation, while speaking to a group of journalists on the sidelines of ICFP 2016.

Last November, the Gates Foundation had announced that it would invest an additional US$120 million in FP programs over the next three years to meet the Family Planning 2020 goal of giving 120 million additional women and girls’ access to contraceptives.

“If there is spacing, half of the lives lost would be saved. Women should be able to decide when they should have babies,” believes Elias.

Health ministry officials in India seem to be moving forward in the right direction. However, there is quite some distance to travel before the revised plans are implemented, cautions Poonam Muttreja, Executive Director, Population Foundation of India.

“Apart from issues like inadequate budget allocation, the bigger challenge India faces is wide disparities and inequities in women’s access to healthcare and family planning. Access to health services still depends upon where one lives, how educated one is, and economic and social status”, says Muttreja.

Clearly, the approach will have to go beyond simply making these choices available at various health centres. “It is not just about making the full range of methods available,” says Elias. “Women have to be empowered to make those choices”.

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At the recent International Conference on Family Planning, Indian health ministry officials committed to make available better quality family planning services and expanding contraceptive choices. How much of that will translate into action will depend on the money allocated to health care in this budget.

India has promised to meet the FP2020 goal of providing 48 million additional women and girls in the country with access to modern contraceptives by 2020. Family Planning 2020 is a global partnership that is working with governments, civil society, donors and the private sector to enable 120 million women and girls to decide for themselves, whether, when, and how many children they want.

Reaching 48 million, however, seems like a tall order. India spends just 1.3% of the GDP on health care, which is lower than other countries. China, for instance, spends 2.8% and South Africa 4.1%. Budget 2014-15 saw an 87% drop in funds allocated to family welfare and this was reduced even further by 34% in 2015-16.

The low priority is baffling given that India has among the worst maternal and infant mortality rates in the world. The role family planning plays in achieving broader development goals, including poverty reduction has been well documented.

Population Foundation of India figures show that 46% couples in India do not practise family planning, About 21% of births every year are unplanned, due to lack of access to contraceptives. The cost of unplanned children, according to a PFI study ranges from 2% of state GDP in Tamil Nadu to 14% in Bihar.

In this context, the Health Ministry’s decision to introduce injectable contraceptives in government health centres is a welcome move. The decision was pending for nearly 15 years due to protests from many women’s rights groups. It also plans to promote spacing methods and improve quality of care.

“Meeting the FP2020 goal would need an investment of approximately Rs 13500 crore over seven years (2014 to 2020)”, points out Poonam Muttreja, Executive Director, Population Foundation of India. An additional Rs 11,150 crore would be needed over the next four years, which is Rs 2800 crore per year, adds Muttreja.

Supplying injectables alone will not is be enough say experts. The government needs to rethink its approach towards family planning.

“If you are talking of FP2020 goals, a lot depends on involving men”, says Ashok Dyalchand, Director, Institute of Health Management in Pachod, Maharashtra. “Not enough has been done to involve men and you have a significant proportion of women using contraception without their husbands’ knowledge.”

“The emphasis has been largely on methods for women historically”, adds Muttreja. “The public health system, FP programmes and communication strategies have to change to encourage male engagement”.

For decades India has depended on female sterilization as a means of contraception. It conducts the highest number of tubal ligations – nearly five million in a year. Data from the first phase of the National Family Health Survey (NFHS-4) shows that female sterilisation accounts for 34% of modern contraceptive methods, while less than 1% men go for a vasectomy

One of the main reasons for the low prevalence are the many myths and misconceptions relating to vasectomy says Emily Jane Sullivan from the London School of Hygiene and Tropical Medicines.

“A tubal ligation is a more complicated, costly, and risky procedure than vasectomy”, says Sullivan. “However, in India, more than 1 in 3 women choose to have a tubal ligation while only 1 in 100 men choose to have a vasectomy.”

Countries like Bhutan, Brazil, Nepal, and Rwanda have countered these myths effectively through campaigns that frame men who choose vasectomy as responsible and caring towards their families.

“There is an opportunity for these countries to share their ‘lessons learned’ with other national family planning programs that are looking to thoughtfully, ethically, and effectively promote vasectomy”, says Sullivan.

India needs to look at similar approaches instead of simply adding more to the basket of choices say experts.

“The only addition to the basket is injectables. We do not have male contraceptives. I am in favour of injectables but whether diligence will go into administering it in the government sector is a concern. There is also the question of a strong provider preference towards tubectomies”, cautions Dyalchand.

For decades India has followed a targets and incentives based approach towards family planning. Achieving the FP2020 goal involves a shift away from that. It is not just about technical solutions or contraception, but also about women’s agency, choice, quality of reproductive health services and dignity.